Impact of traumatic subarachnoid hemorrhage on outcome in nonpenetrating head injury

Part I: A proposed computerized tomography grading scale

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  • 1 Divisions of Neurological Surgery and Neuroradiology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and Department of Mathematics, Arizona State University, Tempe, Arizona
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✓ The presence of traumatic subarachnoid hemorrhage (tSAH) on admission computerized tomography (CT) scans obtained from patients suffering from severe, nonpenetrating head injury has been shown to be associated with a worse outcome than the injury alone would warrant. However, no previous study has provided a simple means of relating the amount of tSAH, its location, or other abnormal findings on initial head CT scans to outcome in patients with nonpenetrating head injury. In this study, admission head CT scans from 252 patients with tSAH, treated at a single institution, were reviewed to ascertain thickness of the tSAH; its location; evidence of mass lesion(s); shift of midline structures (≤ 5 mm vs. > 5 mm); basal cistern effacement; and cortical sulcal effacement. The CT scans were then organized into Grades 1 to 4 with 1 indicating thin tSAH (≤ 5 mm); 2, thick tSAH (> 5 mm); 3, thin tSAH with mass lesion(s); and 4, thick tSAH with mass lesion(s). A stepwise regression analysis of CT features ranked them in descending order of contribution to Glasgow Outcome Scale (GOS) scores at the time of discharge from acute hospitalization as follows: basal cistern effacement, thickness of tSAH, cortical sulcal effacement, presence of mass lesion(s), and location of tSAH. A shift of midline structures was not found to be a significant variable. Further analysis comparing CT grades and admission postresuscitation Glasgow Coma Scale (GCS) scores was highly significant. Patients with lower CT grades had better admission GCS values and discharge GOS scores than those with higher CT grades. From their experience, the authors conclude that their CT grading scale is simple and reliable and relates significantly to outcome at the time of discharge from acute hospitalization.

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  • 1.

    Adams JH, , Doyle D, & Graham DI, et al: The contusion index: a reappraisal in human and experimental non-missile head injury. Neuropathol Appl Neurobiol 11:299308, 1985 Adams JH, Doyle D, Graham DI, et al: The contusion index: a reappraisal in human and experimental non-missile head injury. Neuropathol Appl Neurobiol 11:299–308, 1985

    • Search Google Scholar
    • Export Citation
  • 2.

    Adams JH, , Graham DI, & Gennarelli TA, et al: Diffuse axonal injury in non-missile head injury. J Neurol Neurosurg Psychiatry 54:481483, 1991 Adams JH, Graham DI, Gennarelli TA, et al: Diffuse axonal injury in non-missile head injury. J Neurol Neurosurg Psychiatry 54:481–483, 1991

    • Search Google Scholar
    • Export Citation
  • 3.

    Adams JH, , Graham DI, & Murray LS, et al: Diffuse axonal injury due to nonmissile head injury in humans: an analysis of 45 cases. Ann Neurol 12:557563, 1982 Adams JH, Graham DI, Murray LS, et al: Diffuse axonal injury due to nonmissile head injury in humans: an analysis of 45 cases. Ann Neurol 12:557–563, 1982

    • Search Google Scholar
    • Export Citation
  • 4.

    Arutiunov AI, , Baron MA, & Majorova NA: The role of mechanical factors in the pathogenesis of short-term and prolonged spasm of the cerebral arteries. J Neurosurg 40:459472, 1974 Arutiunov AI, Baron MA, Majorova NA: The role of mechanical factors in the pathogenesis of short-term and prolonged spasm of the cerebral arteries. J Neurosurg 40:459–472, 1974

    • Search Google Scholar
    • Export Citation
  • 5.

    Awad IA, , Carter LP, & Spetzler RF, et al: Clinical vasospasm after subarachnoid hemorrhage: response to hypervolemic hemodilutional and arterial hypertension. Stroke 18:365372, 1987 Awad IA, Carter LP, Spetzler RF, et al: Clinical vasospasm after subarachnoid hemorrhage: response to hypervolemic hemodilutional and arterial hypertension. Stroke 18:365–372, 1987

    • Search Google Scholar
    • Export Citation
  • 6.

    Baker AJ, , Moulton RJ, & MacMillan VH, et al: Excitatory amino acids in cerebrospinal fluid following traumatic brain injury in humans. J Neurosurg 79:369372, 1993 Baker AJ, Moulton RJ, MacMillan VH, et al: Excitatory amino acids in cerebrospinal fluid following traumatic brain injury in humans. J Neurosurg 79:369–372, 1993

    • Search Google Scholar
    • Export Citation
  • 7.

    Baker SP, , O'Neill B, & Haddon W Jr, et al: The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14:187196, 1974 Baker SP, O'Neill B, Haddon W Jr, et al: The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14:187–196, 1974

    • Search Google Scholar
    • Export Citation
  • 8.

    Bouma GJ, , Muizelaar JP, & Choi SC, et al: Cerebral circulation and metabolism after severe traumatic brain injury: the elusive role of ischemia. J Neurosurg 75:685693, 1991 Bouma GJ, Muizelaar JP, Choi SC, et al: Cerebral circulation and metabolism after severe traumatic brain injury: the elusive role of ischemia. J Neurosurg 75:685–693, 1991

    • Search Google Scholar
    • Export Citation
  • 9.

    Braakman R: Multicentre trials on the efficacy of nimodipine on outcome after severe head injury. J Neurotrauma 10 (Suppl):S85, 1993 (Abstract) Braakman R: Multicentre trials on the efficacy of nimodipine on outcome after severe head injury. J Neurotrauma 10 (Suppl):S85, 1993 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 10.

    Bullock R, & Fujisawa H: The role of glutamate antagonists for the treatment of CNS injury. J Neurotrauma 9 (Suppl 2):S443S462, 1992 Bullock R, Fujisawa H: The role of glutamate antagonists for the treatment of CNS injury. J Neurotrauma 9 (Suppl 2):S443–S462, 1992

    • Search Google Scholar
    • Export Citation
  • 11.

    Chan KH, , Dearden NM, & Miller JD: The significance of posttraumatic increase in cerebral blood flow velocity: a transcranial Doppler ultrasound study. Neurosurgery 30:697700, 1992 Chan KH, Dearden NM, Miller JD: The significance of posttraumatic increase in cerebral blood flow velocity: a transcranial Doppler ultrasound study. Neurosurgery 30:697–700, 1992

    • Search Google Scholar
    • Export Citation
  • 12.

    Chesnut RM, , Marshall LF, & Klauber MR, et al: The role of secondary brain injury in determining outcome from severe head injury. J Trauma 34:216222, 1993 Chesnut RM, Marshall LF, Klauber MR, et al: The role of secondary brain injury in determining outcome from severe head injury. J Trauma 34:216–222, 1993

    • Search Google Scholar
    • Export Citation
  • 13.

    Cordobés F, , de la Fuente M, & Lobato RD, et al: Intraventricular hemorrhage in severe head injury. J Neurosurg 58:217222, 1983 Cordobés F, de la Fuente M, Lobato RD, et al: Intraventricular hemorrhage in severe head injury. J Neurosurg 58:217–222, 1983

    • Search Google Scholar
    • Export Citation
  • 14.

    Eisenberg HM, , Gary HE Jr, & Aldrich EF, et al: Initial CT findings in 753 patients with severe head injury. A report from the NIH Traumatic Coma Data Bank. J Neurosurg 73:688698, 1990 Eisenberg HM, Gary HE Jr, Aldrich EF, et al: Initial CT findings in 753 patients with severe head injury. A report from the NIH Traumatic Coma Data Bank. J Neurosurg 73:688–698, 1990

    • Search Google Scholar
    • Export Citation
  • 15.

    The European Study Group on Nimodipine in Severe Head Injury: a multicenter trial of the efficacy of nimodipine on outcome after severe head injury. J Neurosurg 80:797804, 1994 The European Study Group on Nimodipine in Severe Head Injury: a multicenter trial of the efficacy of nimodipine on outcome after severe head injury. J Neurosurg 80:797–804, 1994

    • Search Google Scholar
    • Export Citation
  • 16.

    Fisher CM, , Kistler JP, & Davis JM: Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:19, 1980 Fisher CM, Kistler JP, Davis JM: Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:1–9, 1980

    • Search Google Scholar
    • Export Citation
  • 17.

    Gennarelli TA, , Spielman GM, & Langfitt TW, et al: Influence of the type of intracranial lesion on outcome from severe head injury. A multicenter study using a new classification system. J Neurosurg 56:2632, 1982 Gennarelli TA, Spielman GM, Langfitt TW, et al: Influence of the type of intracranial lesion on outcome from severe head injury. A multicenter study using a new classification system. J Neurosurg 56:26–32, 1982

    • Search Google Scholar
    • Export Citation
  • 18.

    Graham DI, , Lawrence AE, & Adams JH, et al: Brain damage in fatal non-missile head injury without high intracranial pressure. J Clin Pathol 41:3437, 1988 Graham DI, Lawrence AE, Adams JH, et al: Brain damage in fatal non-missile head injury without high intracranial pressure. J Clin Pathol 41:34–37, 1988

    • Search Google Scholar
    • Export Citation
  • 19.

    Hill AB: A Short Textbook of Medical Statistics. London: Hodder and Stoughton, 1977, pp 118126 Hill AB: A Short Textbook of Medical Statistics. London: Hodder and Stoughton, 1977, pp 118–126

    • Search Google Scholar
    • Export Citation
  • 20.

    Hunt WE, , Kassell N, & Pertuiset B, et al: Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg 68:985986, 1988 (Letter) Hunt WE, Kassell N, Pertuiset B, et al: Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg 68:985–986, 1988 (Letter)

    • Search Google Scholar
    • Export Citation
  • 21.

    Jennett B, & Bond M: Assessment of outcome after severe brain damage. A practical scale. Lancet 1:480484, 1975 Jennett B, Bond M: Assessment of outcome after severe brain damage. A practical scale. Lancet 1:480–484, 1975

    • Search Google Scholar
    • Export Citation
  • 22.

    Kistler JP, , Crowell RM, & Davis KR, et al: The relation of cerebral vasospasm to the extent and location of subarachnoid blood visualized by CT scan: a prospective study. Neurology 33:424436, 1983 Kistler JP, Crowell RM, Davis KR, et al: The relation of cerebral vasospasm to the extent and location of subarachnoid blood visualized by CT scan: a prospective study. Neurology 33:424–436, 1983

    • Search Google Scholar
    • Export Citation
  • 23.

    LeRoux PD, , Haglund MM, & Newell DW, et al: Intraventricular hemorrhage in blunt head trauma: an analysis of 43 cases. Neurosurgery 31:678684, 1992 LeRoux PD, Haglund MM, Newell DW, et al: Intraventricular hemorrhage in blunt head trauma: an analysis of 43 cases. Neurosurgery 31:678–684, 1992

    • Search Google Scholar
    • Export Citation
  • 24.

    Levin HS, , Amparo EG, & Eisenberg HM, et al: Magnetic resonance imaging after closed head injury in children. Neurosurgery 24:223227, 1989 Levin HS, Amparo EG, Eisenberg HM, et al: Magnetic resonance imaging after closed head injury in children. Neurosurgery 24:223–227, 1989

    • Search Google Scholar
    • Export Citation
  • 25.

    Levin HS, , Williams DH, & Valastro M, et al: Corpus callosal atrophy following closed head injury: detection with magnetic resonance imaging. J Neurosurg 73:7781, 1990 Levin HS, Williams DH, Valastro M, et al: Corpus callosal atrophy following closed head injury: detection with magnetic resonance imaging. J Neurosurg 73:77–81, 1990

    • Search Google Scholar
    • Export Citation
  • 26.

    Levy ML, , Rezai A, & Masri LS, et al: The significance of subarachnoid hemorrhage after penetrating craniocerebral injury: correlations with angiography and outcome in a civilian population. Neurosurgery 32:532540, 1993 Levy ML, Rezai A, Masri LS, et al: The significance of subarachnoid hemorrhage after penetrating craniocerebral injury: correlations with angiography and outcome in a civilian population. Neurosurgery 32:532–540, 1993

    • Search Google Scholar
    • Export Citation
  • 27.

    Luerssen TG, , Hults K, & Klauber M, et al: Improved outcome as a result of recognition of absent or compressed cisterns on initial CT scans, in Hoff JT, & Betz AL (eds): Intracranial Pressure VII. Berlin: Springer-Verlag, 1989, pp 598602 Luerssen TG, Hults K, Klauber M, et al: Improved outcome as a result of recognition of absent or compressed cisterns on initial CT scans, in Hoff JT, Betz AL (eds): Intracranial Pressure VII. Berlin: Springer-Verlag, 1989, pp 598–602

    • Search Google Scholar
    • Export Citation
  • 28.

    Marion DW, , Obrist WD, & Carlier PM, et al: The use of moderate therapeutic hypothermia for patients with severe head injuries: a preliminary report. J Neurosurg 79:354362, 1993 Marion DW, Obrist WD, Carlier PM, et al: The use of moderate therapeutic hypothermia for patients with severe head injuries: a preliminary report. J Neurosurg 79:354–362, 1993

    • Search Google Scholar
    • Export Citation
  • 29.

    Marmarou A, , Ward JD, & Young HF, et al: Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 75 (Suppl):S59S66, 1991 Marmarou A, Ward JD, Young HF, et al: Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 75 (Suppl):S59–S66, 1991

    • Search Google Scholar
    • Export Citation
  • 30.

    Marshall LF, , Marshall SB, & Klauber MR, et al: A new classification of head injury based on computerized tomography. J Neurosurg 75 (Suppl):S14S20, 1991 Marshall LF, Marshall SB, Klauber MR, et al: A new classification of head injury based on computerized tomography. J Neurosurg 75 (Suppl):S14–S20, 1991

    • Search Google Scholar
    • Export Citation
  • 31.

    Martin NA, , Doberstein C, & Khanna R, et al: Post traumatic cerebral arterial spasm. J Neurotrauma 10 (Suppl):S84, 1993 (Abstract) Martin NA, Doberstein C, Khanna R, et al: Post traumatic cerebral arterial spasm. J Neurotrauma 10 (Suppl):S84, 1993 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 32.

    Martin NA, , Doberstein C, & Zane C, et al: Posttraumatic cerebral arterial spasm: transcranial Doppler ultrasound, cerebral blood flow, and angiographic findings. J Neurosurg 77:575583, 1992 Martin NA, Doberstein C, Zane C, et al: Posttraumatic cerebral arterial spasm: transcranial Doppler ultrasound, cerebral blood flow, and angiographic findings. J Neurosurg 77:575–583, 1992

    • Search Google Scholar
    • Export Citation
  • 33.

    Rinkel GJ, , Wijdicks EF, & Vermeulen M, et al: Nonaneurysmal perimescencephalic subarachnoid hemorrhage: CT and MR patterns that differ from aneurysmal rupture. AJNR 12:829834, 1991 Rinkel GJ, Wijdicks EF, Vermeulen M, et al: Nonaneurysmal perimescencephalic subarachnoid hemorrhage: CT and MR patterns that differ from aneurysmal rupture. AJNR 12:829–834, 1991

    • Search Google Scholar
    • Export Citation
  • 34.

    Rinkel GJE, , Wijdicks EFM, & Vermeulen M, et al: The clinical course of perimesencephalic nonaneurysmal subarachnoid hemorrhage. Ann Neurol 29:463468, 1991 Rinkel GJE, Wijdicks EFM, Vermeulen M, et al: The clinical course of perimesencephalic nonaneurysmal subarachnoid hemorrhage. Ann Neurol 29:463–468, 1991

    • Search Google Scholar
    • Export Citation
  • 35.

    Rinkel GJE, , Wijdicks EFM, & Vermeulen M, et al: Outcome in perimesencephalic (nonaneurysmal) subarachnoid hemorrhage: a follow-up study in 37 patients. Neurology 40:11301132, 1990 Rinkel GJE, Wijdicks EFM, Vermeulen M, et al: Outcome in perimesencephalic (nonaneurysmal) subarachnoid hemorrhage: a follow-up study in 37 patients. Neurology 40:1130–1132, 1990

    • Search Google Scholar
    • Export Citation
  • 36.

    Sahuquillo J, , Vilalta J, & Lamarca J, et al: Diffuse axonal injury after severe head trauma. A clinico-pathological study. Acta Neurochir 101:149158, 1989 Sahuquillo J, Vilalta J, Lamarca J, et al: Diffuse axonal injury after severe head trauma. A clinico-pathological study. Acta Neurochir 101:149–158, 1989

    • Search Google Scholar
    • Export Citation
  • 37.

    Sahuquillo-Barris J, , Lamarca-Ciuro J, & Vilalta-Castan J, et al: Acute subdural hematoma and diffuse axonal injury after severe head trauma. J Neurosurg 68:894900, 1988 Sahuquillo-Barris J, Lamarca-Ciuro J, Vilalta-Castan J, et al: Acute subdural hematoma and diffuse axonal injury after severe head trauma. J Neurosurg 68:894–900, 1988

    • Search Google Scholar
    • Export Citation
  • 38.

    Shigemori M, , Tokutomi T, & Kuramoto S, et al: Diffuse axonal injury and early intracranial sequelae in severe head injury. Neurol Med Chir 31:390395, 1991 Shigemori M, Tokutomi T, Kuramoto S, et al: Diffuse axonal injury and early intracranial sequelae in severe head injury. Neurol Med Chir 31:390–395, 1991

    • Search Google Scholar
    • Export Citation
  • 39.

    Spetzler RF, & Martin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65:476483, 1986 Spetzler RF, Martin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65:476–483, 1986

    • Search Google Scholar
    • Export Citation
  • 40.

    Suwanwela C, & Suwanwela N: Intracranial arterial narrowing and spasm in acute head injury. J Neurosurg 36:314323, 1972 Suwanwela C, Suwanwela N: Intracranial arterial narrowing and spasm in acute head injury. J Neurosurg 36:314–323, 1972

    • Search Google Scholar
    • Export Citation
  • 41.

    Teasdale E, , Cardoso E, & Galbraith S, et al: CT scan in severe diffuse head injury: physiological and clinical correlations. J Neurol Neurosurg Psychiatry 47:600603, 1984 Teasdale E, Cardoso E, Galbraith S, et al: CT scan in severe diffuse head injury: physiological and clinical correlations. J Neurol Neurosurg Psychiatry 47:600–603, 1984

    • Search Google Scholar
    • Export Citation
  • 42.

    Teasdale G, & Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:8184, 1974 Teasdale G, Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84, 1974

    • Search Google Scholar
    • Export Citation
  • 43.

    Toutant SM, , Klauber MR, & Marshall LF, et al: Absent or compressed basal cisterns on first CT scan: ominous predictors of outcome in severe head injury. J Neurosurg 61:691694, 1984 Toutant SM, Klauber MR, Marshall LF, et al: Absent or compressed basal cisterns on first CT scan: ominous predictors of outcome in severe head injury. J Neurosurg 61:691–694, 1984

    • Search Google Scholar
    • Export Citation
  • 44.

    Uzzell BP, , Dolinskas CA, & Wiser RF, et al: Influence of lesions detected by computed tomography on outcome and neuropsychological recovery after severe head injury. Neurosurgery 20:396402, 1987 Uzzell BP, Dolinskas CA, Wiser RF, et al: Influence of lesions detected by computed tomography on outcome and neuropsychological recovery after severe head injury. Neurosurgery 20:396–402, 1987

    • Search Google Scholar
    • Export Citation
  • 45.

    van Dongen KJ, , Braakman R, & Gelpke GJ: The prognostic value of computerized tomography in comatose head-injured patients. J Neurosurg 59:951957, 1983 van Dongen KJ, Braakman R, Gelpke GJ: The prognostic value of computerized tomography in comatose head-injured patients. J Neurosurg 59:951–957, 1983

    • Search Google Scholar
    • Export Citation
  • 46.

    Wilberger JE Jr, , Rothfus WE, & Tabas J, et al: Acute tissue tear hemorrhages of the brain: computed tomography and clinicopathological correlations. Neurosurgery 27:208213, 1990 Wilberger JE Jr, Rothfus WE, Tabas J, et al: Acute tissue tear hemorrhages of the brain: computed tomography and clinicopathological correlations. Neurosurgery 27:208–213, 1990

    • Search Google Scholar
    • Export Citation
  • 47.

    Yokota H, , Kurokawa A, & Otsuka T, et al: Significance of magnetic resonance imaging in acute head injury. J Trauma 31:351357, 1991 Yokota H, Kurokawa A, Otsuka T, et al: Significance of magnetic resonance imaging in acute head injury. J Trauma 31:351–357, 1991

    • Search Google Scholar
    • Export Citation

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